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The Ostomy Files: New HCPCS Codes for Ostomy Supplies
Last year, the Office of Inspector General in the Department of Health and Human Services reported on an investigation into balance billing.1 Medicare beneficiaries with ostomies were experiencing more of a financial burden for the cost of their supplies than were other Medicare beneficiaries. Also, claims for ostomy supplies had a higher rate of nonassignment than other covered medical supplies.
The Government Affairs Committee of the United Ostomy Association (UOA), chaired by Linda Aukett, has been successful in its ongoing efforts to bring about improvements in Medicare policy for the coverage and payment of ostomy supplies. These changes to Medicare policy may pave the way to solutions for these problems. Twenty new temporary "K" HCPCS codes for ostomy supplies, effective April 1, 2002 (Program Memorandum Intermediaries/Carriers, Transmittal AB-02-001, January 11, 2002), reflect technological advances in ostomy products. These new codes hopefully will help achieve more equitable reimbursement rates for ostomy supplies and decrease the out-of-pocket expenses for Medicare beneficiaries with ostomies. The new HCPCS codes function in three ways:
1. "Split codes" replace one existing HCPCS code by creating more specific codes and descriptors for certain products.
2. "Addition to ostomy pouch" codes allow additional and more equitable payment for more advanced features of certain covered products.
3. "New" product codes acknowledge new categories of ostomy products.
"Split" Codes
"Split" codes recognize, differentiate, and reflect separate reimbursement for larger sizes of skin barriers with flanges, different types of skin barrier pastes, one-piece drainable pouches with different types of skin barriers, and waterproof tape. In most cases, two new HCPCS codes replace each of the seven "retired" HCPCS codes.
-- K0561 - Ostomy skin barrier, non-pectin based, paste, per ounce
-- K0562 - Ostomy skin barrier, pectin-based, paste, per ounce
-- Retires: A4370 - Ostomy skin barrier, paste, per ounce
-- K0563 - Ostomy skin barrier, with flange (solid, flexible, or accordion), extended wear, with built-in convexity, 4 inches x 4 inches or smaller, each
-- K0564 - Ostomy skin barrier, with flange (solid, flexible, or accordion), with built-in convexity, larger than 4 inches x 4 inches, each
-- Retires: A4374 - Ostomy skin barrier, with flange (solid, flexible, or accordion), extended-wear, with built-in convexity, any size, each
-- K0565 - Ostomy skin barrier, with flange (solid, flexible, or accordion), extended wear, without built-in convexity, 4 inches x 4 inches or smaller, each
-- K0566 - Ostomy skin barrier, with flange (solid, flexible, or accordion), extended wear, without built-in convexity, larger than 4 inches x 4 inches, each
-- Retires: A4386 - Ostomy skin barrier, with flange (solid, flexible or accordion), extended wear, without built-in convexity, any size, each
-- K0567 - Ostomy pouch, drainable, with karaya based barrier attached, without built-in convexity, (1 piece), each
-- K0568 - Ostomy pouch, drainable, with standard wear barrier attached, without built-in convexity, (1 piece), each
-- Retires: A5061 - Pouch, drainable; with barrier attached (1 piece)
-- K0570 - Ostomy skin barrier, with flange (solid, flexible, accordion), without built-in convexity, 4 inches x 4 inches or smaller, each
-- K0571 - Ostomy skin barrier, with flange (solid, flexible, accordion), without built-in convexity, larger than 4 inches x 4 inches, each
-- Retires: A5123 - Skin barrier; with flange (solid, flexible, or accordion), any size, each
-- K0572 - Tape, non-waterproof, per 18 square inches
-- K0573 - Tape, waterproof, per 18 square inches
-- Retires: A6265 - Tape, all types, per 18 square inches.
"Addition to Ostomy Pouch" Feature Codes
These HCPCS codes are a new approach for billing ostomy supplies; some of them identify integral features ("addition to") of a particular product that may be billed and paid in addition to the payment for product itself. Before these new codes were implemented, a single HCPCS code and payment level applied to all brands of products within a category without consideration of their individual and often more advanced features.
-- K0574 - Addition to ostomy pouch, filter, integral or added separately to pouch, each
-- Retires: A4368 - Ostomy filter, any type, each
-- K0575 - Addition to ostomy pouch, rustle-free material, per pouch
-- K0576 - Addition of ostomy pouch, friction and irritant-reducing, absorbent, interface layer (comfort panel), per pouch
-- K0577 - Addition to ostomy pouch, odor barrier, incorporated into pouch laminate, per pouch
-- K0578 - Addition to ostomy pouch, faucet-type tap with valve for draining urinary pouch, each
-- K0580 - Addition to ostomy pouch, flange- locking mechanism, each (the mechanism itself may be incorporated either in the pouch flange or the skin barrier flange).
Billing for as many as six HCPCS codes may now be necessary for a single pouch. An example would be a two-piece, closed pouch with an integral filter, comfort panel, odor barrier, rustle-free pouch material, and a flange-locking mechanism. Billing codes for additional payments for the features integral to the two-piece, closed pouch described above include:
1. A5054 - Pouch, closed, for use on barrier with flange (two-piece system)
2. K0574 - Addition to ostomy pouch, filter, integral or added separately to pouch, each
3. K0576 - Addition to ostomy pouch, friction and irritant-reducing, absorbent, interface layer (comfort panel), per pouch
4. K0575 - Addition to ostomy pouch, rustle-free material, per pouch
5. K0577 - Addition to ostomy pouch, odor-proof material, per pouch
6. K0580 - Addition to ostomy pouch, flange- locking mechanism.
New Product Codes
Two new ostomy product categories have been created:
-- K0569 - Ostomy pouch, drainable, high output, for use on barrier with flange two-piece system), each
-- K0579 - Absorbent material (sheet/pad/crystal packet) to thicken liquid stomal output, for use in pouch, each
New Ostomy Temporary K HCPCS Codes
The seven replaced HCPCS codes were retired on April 1, 2002. The DMERCs must receive claims using the old codes by June 30, 2002.
Medicare fee schedule amounts are to be issued in mid-March. These policy changes and changes effective as of October 2000 will be formally incorporated in a revised policy by July 1, 2002. Due to publishing deadlines, including the fees for the new “K” codes in the April issue of Ostomy/Wound Management is not possible. However, introducing these codes will go a considerable way toward improving reimbursement levels and increasing the ability of medical suppliers to accept Medicare assignment for ostomy supplies. The UOA Government Affairs Committee has recommended either an increase or no change to the fees for all new K codes when compared to the codes they replace.
No additional medical justification (documentation) will be required for coverage and payment of the "addition to ostomy pouch" feature codes. Prescriptions for ostomy pouches will not need to specify which particular features besides pouch type (eg, closed, urinary, drainable) a pouch should have.
Conclusion
With input from ostomy manufacturers, the UOA and the Statistical Analysis Durable Medical Equipment Regional Carrier (SADMERC) are working together to develop a comprehensive list of all brands of ostomy products with appropriate HCPCS codes, similar to the list provided for surgical dressings.
The establishment of new coverage policies, payment levels, and billing codes is a time-consuming and tedious process. Linda Aukett and the members of her UOA committee, the WOCN, suppliers and manufacturers, the SADMERC, and the four Medical Directors at the DMERCs are to be congratulated for their diligence, openness, and dedication to Medicare beneficiaries with ostomies.
